Director of Utilization Management

Director of Utilization Management job, Full-Time, Nashville, Tennessee

Nashville General Hospital is hiring for a Director of Utilization Management as a full time job in Nashville, Tennessee.

The Director functions as the internal resource on issues related to the appropriate utilization of resources, coordination of care across the continuum and utilization review and management. The Manager is responsible for carrying out assignments in a manner to assure success in financial management, human resources management, leadership, quality and operational management objectives.

Director of Utilization Management Roles & Responsibilities: 

• Lead and direct the coordination and facilitation of correct identification of patient status.
• Direct, implement, and integrate all UM functions including Denials Management.
• Manage, implement and integrate Pre-certification functions.
• Collaborate with all members of the healthcare team, both internal and external customers.
• Participate in clinical performance improvement activities to achieve set goals.
• Oversight of clinical documentation improvement services, ensuring a patient's medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patient's health status.
• Responsible for the planning, organizing, and directing of the organization's operations and programs.
• Develops and implements consistent inventory and cost accounting policies, procedures, and operational reporting/metrics. Oversees and reports on the company results for senior management.
• Lead and direct the overall operation of the utilization management function to ensure consistency of policies, procedures and workflows through IT integrations.
• Evaluate utilization management program effectiveness and recommend improvements, including needs analysis and planning.
• Ensures provider satisfaction with utilization management program.
• Ensure utilization management targets for all products are met for the annual operating plan, state requirements and financial management.
• Ensure that utilization management process is integrated with case management program and CDI.
• Maintain compliance with National Committee for Quality Assurance (NCQA) standards for case management functions and Joint Commision.
• Develop and implement methods, policies and procedures to improve the departments efficiency and effectiveness.
• Identify quality and risk management issues and facilitate the collection of information for quality improvement and reporting.
• Review various reports and identify trends to assist in financial forecasting.
• Responsibility for developing, organizing, planning and executing an action oriented interdisciplinary Utilization Review Committee with consistent physician support.
• Ensures peer to peer completion in partnership with physicians.

Required Skills & Qualifications: 

• Bachelor's degree in nursing, related field, or equivalent experience
• 5-7+ years of utilization management, clinical nursing, CDI and quality improvement experience in a managed care setting.
• Two years of management experience preferred (Preferably Utilization Review or CDI)
• Experience in CDI and Coding in healthcare setting.
• Current Licensure or permit to practice as a Registered Nurse in the State of Tennessee or compact state.

About Nashville General Hospital

Nashville General Hospital (NGH) is Nashville’s original community- based hospital. Joint Commission accredited, NGH readily accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH continues to maintain its strong commitment to the healthcare needs of Nashville and Davidson County underserved, while also providing care to all segments of the community.

Our benefits include:

• Medical, Dental, and Vision Insurance